1. Field of the Invention
This invention relates generally to automatic document formulation and, more particularly, to a system and method of creating a clinical resume from mining an electronic database.
2. Description of the Related Art
Traditionally, after a patient is discharged, the physician dictates, or perhaps writes by hand, a clinical resume. A clinical resume can be referred to as a medical discharge summary, a transfer summary, a problem list, or an expiration summary. The clinical resume brings the major elements of a patients care, for each specific visit, into focus in a single document. A medical discharge summary, for example, also provides information for additional teaching, and provides the patient with information needed to care for themselves or get further help. The discharge summary from an acute care facility may serve as a tool for the continuum of care.
A discharge summary is only required after a patient has left the facility, and physicians often view discharge summaries as a background task. The urgent needs of current patients rightfully draw the physician's attention, but facilities incur significant costs because of the resulting delay in generating discharge summaries, completing charts, and billing for and receiving reimbursement. However, the regulations are strict and specific regarding the content and format of all discharge summaries. Non-conformance to regulations can place a facility at risk for losing accreditation.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires a discharge summary, or clinical resume, whenever a patient is discharged from an accredited facility, as stated in the JCAHO information management (IM) standards IM.7 through IM.7.2. This document must include history and physical information, diagnoses, any recommendations made by the physicians, and other relevant data.
The JCAHO is a quality oversight body for health care organizations and managed care in the United States. In 1965 congress (Health Care Financing Administration—HCFA) passed the Social Security Amendments with a provision that hospitals accredited by the JCAHO, are “deemed” to be in compliance with most of the Medicare Conditions of Participation for Hospitals, and, thus, able to participate in the Medicare and Medicaid programs. The information management (IM) standards IM.7 through IM.7.2 specify that a concise clinical resume included in the medical record at discharge provides important information to other caregivers and facilities continuity of care.
According to JCAHO, the discharge summary is to be completed with 30 days of each patient discharge. However, many facilities have medical staff bylaws written with a much more stringent completion time frame to comply with the following issues: hospital revenue needs with account receivable goals; continuity of patient care; emergency patient transfer; memory accuracy; and, legal implications. Further, the closure of medical records impacts the facilities billing cycle, optical imaging, data abstraction deadlines, computerized data storage, and internal on-line viewing.
The same JCAHO standards require that the discharge summary contains the following information:                reason for hospitalization;        significant findings;        procedures performed and treatment rendered;        patient's condition at discharge; and        instructions to the patient and family, if any.        
In addition to the above requirements, the discharge summary usually contains the patients' final diagnoses, treatments and procedures performed during that visit.
In 1997 the JCAHO announced the ORYX program which is expected to be the next evolution in accreditation to integrate the use of outcomes and other performance measures into the accreditation process. This announcement has placed many health care organizations on their toes to assure that their data bases contain all of the JCAHO data requirements for use prior to their next accreditation survey at their facilities.
Congress proposed the Health Insurance Portability and Accountability Act (HIPAA) in 1996, that was passed in 2000. Among other requirements, HIPAA mandated the US Department of Health and Human Services (HHS) to develop a set of regulations concerning the privacy and security of health information. HHS issued recommendations and proposed rules that were published in 1998. They apply to providers, payers, and clearinghouses that handle (either store or transmit) individually identifiable healthcare information. More so than any regulatory drivers to date, the HIPAA security regulations will force healthcare organizations to replace paper-based patient medical records with computer-based patient record systems (CPR's).
An increasing number of health plans are requiring copies of discharge summaries and other pertinent portions of the patient medical record for auditing. Not only Medicare and Medicaid fiscal intermediaries, but healthcare plans of the private sector are increasingly auditing for accurate billing and medical necessity.
Auditors, whether off-site or they come to the facility, are double checking the Health Information Coders to substantiate that each code diagnosis and procedure is actually documented in the patient medical record. They also check legitimate medical necessity for admission to the hospital, and that all drugs and equipment being billed, were ordered by a physician.
According to HIPAA regulations, a hospital may only submit claims for services that the hospital has reason to believe are medically necessary and that were ordered by a physician or other appropriately licensed individual.
The Office of Inspector General (OIG) recognizes that licensed health care professionals must be able to order any services that are appropriate for the treatment of their patients. However, Medicare and other government and private health care plans will only pay for those services that meet appropriate medical necessity standards (in the case of Medicare, i.e., reasonable and necessary services). Providers may not bill for services that do not meet the applicable standards.
The hospital is in a unique position to deliver this information to the health care professionals on its staff. Upon request, a hospital should be able to provide documentation, such as patients' medical records and physicians' orders, to support the medical necessity of a service that the hospital has provided.
It is becoming increasingly desirable to provide a fuller record of the patient's stay in the hospital than is provided in the traditional dictated discharge summary. Preparing a discharge summary involves integrating information extracted from several sources with comments from consulting physicians also responsible for the patient.
Beyond administrative concerns, the discharge summary is the last required documentation to be completed after the patient is discharged from the healthcare facility. This document is important to physicians because it acts to provide:
a summary of the patient's medical and surgical history;
general and emergency continuing care information, such as allergies to medication; poor anesthesia risks; drug interactions; and, present diagnoses being treated;
legal proof of appropriate patient care;
billing for physician services;
patient follow-up instruction for further office visits;
physician practice patterns (by diagnoses and procedures); and
physician case load for recertifications.
According to the OIG, every physician who provides or supervises the provision of services to a patient should be responsible for the correct documentation of the services that were rendered. The appropriate documentation must be placed in the patient record and signed by the physician who provided or supervised the provision of services to the patient.
While the importance of the discharge summary to physicians is great, most have difficulty finding time in their busy schedules, with more critical priorities, to complete this documentation. Due to the commitment involved to complete this documentation, many physicians pay to have other staff members dictate the discharge summary for them. The process of generating a discharge summary requires between ten and twenty minutes of the physician's time to read the information and write the discharge information, in addition to the time required to locate and obtain the patient's chart. The summary is in turn transcribed and inserted into the patient's chart like all the other documents generated during their treatment.
This discharge summary is by definition redundant, since every part of a discharge summary is contained in at least one other document. Dictating a discharge summary involves searching through a patient's chart for required and relevant information. A physician can spend about an hour per four or five patients just re-reading previously dictated information. This redundancy, and the overall amount of time involved, often spur physicians or facilities to hire outside labor or other hospital staff to dictate discharge summaries. The savings in physician time comes at the monetary and potential quality cost of using alternative labor.
Computers and software algorithms have been devised to sort and retrieve data, and almost all important medical procedures and events are entered into an electronic database of some sort. However, the medical events are not necessarily stored in the same database. Further, the stored information is not always of a type that is easily retrieved. Predetermined fields, such as name and date of admission are easy to work with, but a significant portion of the medical events are textual diagnosis and observation information that is not necessarily stored by field.
It would be advantageous to automate the preparation of medical discharge summaries, to reduce the amount of physician time and effort required for dictation.
It would be advantageous if an automated discharge summary could be prepared quickly enough that a physician could sign the discharge summary at the same time as the other medical event entrees required to complete and authenticate the record.
It would be advantageous if an automated summary statement could set up to provide a standardized and legible report that makes information easy to find.
It would be advantageous if an automated medical discharge summary could be generated that improved a hospital's position with respect to revenue generation, patient transfers to another facility, legal correspondence, internal on-line viewing, and JCAHO unannounced surveys.
It would be advantageous if all the data necessary to complete a clinical resume could be stored in a data repository for mining. Likewise, it would be advantageous if transcriptions and descriptions, which are difficult to organize by fields, could be stored and mined for use in a clinical resume.
It would be advantageous if a medical summary document could be prepared from source files that have been reviewed, edited, and attested to minimize to amount of human intervention required.